Qualitative Research About Attributions, Narratives, and Support for Obesity Policy, 2008

Introduction Successful efforts to reduce obesity will require public policy strategies that target both individuals and external factors such as social conditions, economic circumstances, and physical environments. Public opinion data suggest that many policy changes to reduce obesity are likely to face public resistance. Methods We conducted 4 focus groups involving 33 adults living in or near a midsized Midwestern city in July 2008. Participants were assigned to the focus groups on the basis of self-reported political ideology. We used a semistructured discussion guide to 1) better understand public perceptions of obesity and 2) assess the promise of narratives as a strategy to stimulate meaningful discussion about obesity-related policy change. Results Participants viewed internal factors as primary causes of obesity. Despite substantial acknowledgment of external causes of obesity, many participants — particularly political conservatives — were resistant to external policy solutions for the problem. Across the political spectrum, participants responded more favorably to a short narrative emphasizing barriers to reducing adult obesity than a story emphasizing barriers to reducing childhood obesity. Conclusion This study provides a deeper context for understanding public perceptions about obesity. Some types of narratives appear promising for promoting support for policy solutions to reduce obesity.


Introduction
Obesity rates are rapidly increasing in the United States, resulting in greater chronic disease risk and reduced quality of life (1). Successful obesity reduction efforts will require new policies to modify external factors such as social, economic, and physical environments (2,3). Policy change to reduce obesity is unlikely without public support. Opinion polls show only mixed support for obesity-reducing policies such as subsidies for fruits and vegetables or zoning laws that promote physical activity and healthy food availability (4,5). More effective communication strategies are needed to increase awareness of social determinants of obesity and promote support for policy changes that target these determinants.
Literature on attributions and narratives (personal stories) can help inform these strategies (6). Attribution theory says that people attribute the causes of other people's dispositions as within a person's control (internal) (eg, too lazy to exercise) or outside of a person's control (external) (eg, lack of safe places for exercise) (7,8). People who think obesity is within internal control are less likely to support policies to create healthier social, economic, and physical (external) environments (9,10) conservatives are more likely than liberals to think obesity is within internal control (9), less likely to support obesity policies (10), and less responsive to news stories highlighting social determinants of obesity (11).
Narratives facilitate attitude and behavior change by connecting readers with characters that represent broader populations (12,13). Personal stories can successfully emphasize structural causes of social problems (14,15) and are a part of many recent campaigns to increase awareness of social determinants of health (16). We used focus group data to explore issues involved with the development of narratives to promote policies for reducing obesity rates. We asked 2 research questions: How do participants conceptualize attributions for obesity in their own terms? How do attributions and responses to obesity narratives vary by political partisanship or topic (eg, adult vs childhood obesity)?

Design and setting
Thirty-three adults from the metropolitan area of a midsized Midwestern city participated in 1 of 4 focus groups in July 2008. We used a sample of listed telephone numbers to recruit adult participants. Inclusion criteria required participants to intend to vote in the 2008 presidential election and to self-identify as a Democrat, Republican, liberal Independent/Other Party, or conservative Independent/ Other Party. We excluded Independents and members of other parties if they self-identified as politically moderate. We asked eligible participants to participate in a focus group about health and weight-related issues. To avoid polarized discussions about attributions and policy (9-11), we assigned participants to groups by political ideology, producing 2 sessions for liberals/Democrats, Lib A and Lib B, and 2 sessions for conservatives/Republicans, Cons A and Cons B.

Focus group protocol
The University of Wisconsin's Social and Behavioral Sciences institutional review board approved the study. A trained moderator led participants in 2-hour focus group sessions, using the same base questions and probes about factors that cause obesity, solutions for high rates of obesity, and attributions of responsibility for solving the problem (Appendix). Halfway through the session, we asked participants to read 1 of 2 narratives emphasizing external causes of obesity and to share their thoughts on the story. After the discussion, participants completed a short demographic questionnaire. Two groups read a narrative that framed obesity as an adult issue (www.cdc.gov/obesity) and 2 groups read a narrative that framed obesity as a childhood issue (www.rwjf.org/childhoodobesity).

Narratives
Adult obesity narrative. One group from each political ideology (Lib A and Cons A) read a story about a young adult named John Stevenson who lived in a poor neighborhood and had difficulty losing weight. We adapted and made several modifications to the story of a real person depicted by the Robert Wood Johnson Foundation's (16) Commission to Build a Healthier America. We changed the race of the main character from black to white to avoid priming racial stereotypes (17). The story acknowledged personal decisions (internal causes) but emphasized social barriers, including cost and availability of healthy food, stress associated with a low-income job, and lack of safe and affordable places for exercise (external causes).
Childhood obesity narrative. The other groups (Lib B and Cons B) read a story about a boy named Jimmy Collins who lived in a rural area and had steadily gained weight during the past year. We adapted the story of a real family depicted in a Washington Post article and supplemented it with material from a Time article (18,19). We changed the race of the family from Hispanic to white to avoid priming racial stereotypes. The story described weight-loss strategies that Jimmy and his mother tried (internal causes); it also described time, financial, and availability barriers faced by Jimmy and his parents (external causes).

Data analysis
The first author used N6 qualitative analysis software (QSR International, Cambridge, Massachusetts) to identify recurring themes and to classify statements in transcripts The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
of each discussion. Coding began with a set of categories that mirrored the structure of the focus group protocol but also allowed for the inductive identification of codes as new themes emerged. On the basis of an ecological framework, we classified causes of obesity as internal or external (2). We classified solutions to obesity into 4 categories: 1) internal -alone, 2) internal -educational, 3) external -social/ organizational, and 4) external -legislative. Although a focus on individual knowledge through education implies external involvement, we classified this strategy as internal because it ultimately places responsibility on individuals to acquire knowledge and put it into practice (1,20,21). Furthermore, although receiving social support or participating in school or workplace initiatives often requires some individual motivation, we classified these strategies as external because they require effort or investment from people or organizations beyond the individual. We highlight differences in response by ideology (liberal vs conservative) or exposure to the 2 narratives (adult vs childhood) only when clear patterns of difference emerged across groups.

Results
Perceived causes of obesity: prenarrative exposure Many cited time constraints from long and stressful work hours as causes of obesity. Some discussed workplace culture, which may encourage unhealthy food decisions, or mentioned the lack of physical and nutrition education and the availability of junk food in schools.
Each group identified the physical and media environments as causes of overweight. Participants mentioned extreme weather, neighborhood safety, city sprawl, lack of public transport, and other elements of city design as impediments to exercise. Several participants made explicit comparisons between the United States and other countries: "Most of Europe did not evolve with the automobile the way we did and [Europe] . . . is set up in such a way that it is easy to walk and bicycle a lot of places" (woman, Lib A). Participants in each group also discussed ways that television, video games, and other media encourage sedentary behavior (time not spent exercising) and unhealthy diets (aggressive marketing of unhealthy food).
Perceived solutions to high rates of obesity: prenarrative exposure

Internal -alone. Although each group offered several
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
possible solutions to high rates of obesity, many participants voiced the opinion that responsibility for obesity rests solely with individuals (internal) or their parents (if they are children). These sentiments were offered more frequently in conservative groups but also appeared regularly among liberals.
Internal -educational. The internally focused strategies were the most common solutions cited among both liberals and conservatives: 1) strengthening individual knowledge, particularly in schools, and 2) community education such as public education campaigns at the community for national level. These strategies imply some degree of public investment but ultimately reflect internal attributions: people are responsible for making good decisions about diet and exercise when information is available. Before reading the narrative, each group concluded that enhancing diet and exercise-related education was the best strategy for reducing obesity rates.
External. Participants offered 3 types of external solutions, although less frequently than internal solutions: 1) increasing social support (without legislation), 2) changing organizational practices (without legislation), and 3) influencing public policy and legislation. Liberals and conservatives each discussed social support and organizational practices, but clear ideological differences emerged for legislation to help reduce obesity rates.
External -social/organizational. Three of the 4 groups mentioned the importance of increasing social support for nutrition and exercise. Each group also discussed the importance of organizations, including schools (lunch programs, vending machines, recess, and exercise facilities), insurance companies (incentives for diet and exercise), workplaces (onsite facilities and classes), restaurants (healthier choices and reduced portion size), or businesses (target fitness clubs or food delivery services to overweight, elderly, or low-income populations).

External -legislative.
Liberal groups offered a few legislative options to reduce obesity. Liberal groups discussed junk food taxes to reduce unhealthy food consumption and gasoline taxes to encourage physical activity. Several conservative participants explicitly rejected these ideas without prompt. For instance, 1 man (Cons B) said, "Boy, not taxes. Make sure that's in there [laughter, agreement]." Liberal groups also discussed food advertising bans, mandatory media-use restrictions, and city planning for healthier environments. Conservative groups mentioned only mandatory food labeling as a public policy. Although legislative, this strategy implies internal responsibility for making informed decisions about diet.

Resonant themes in response to obesity narratives
We observed striking differences in the responses to the adult and childhood obesity narratives. These differences stood in stark contrast to the minor differences observed between liberal and conservative groups.
Adult obesity narrative. A common response to the adult story focused on factors external to John, such as the social, economic, and physical conditions that contribute to obesity. For instance, 1 man (Cons A) said, "What stresses people out [is] when they don't have enough money and they . . . make poor decisions. . . . Well this is cheaper, may not be as good for me, but it will fill me up." Another woman (Lib A) summarized, "It seems like from reading . . . that society has stacked a lot of things against him." Empathy and identification with John's intrinsic, internal characteristics reflected a second prominent theme in response to the adult narrative. As 1 man (Cons A) commented, "I saw me in there. . . . I saw a lot of similarities to my lifestyles or my family and friends, stuff like . . . stress, cost, convenience, good choices." Overall, participants who read the adult narrative empathized with the barriers John faced in reducing his weight and admired his resolve in trying to overcome them.

Childhood obesity narrative.
In contrast, comments about the childhood story focused on internal attributions and decisions made by Jimmy's parents. Some of these criticisms were directly related to Jimmy's mother's attempts at managing Jimmy's weight. One man commented (Lib B), "It seems like she's spending money all the time and just throwing it away." Several participants said Jimmy's parents were "making excuses" or criticized their level of involvement with him. Still others focused on incidental aspects of the story that were viewed as broader indicators of bad parenting: "That little kid is allowed to play Halo [a first-person shooter video game], and it's not, not a good parent to let him play Halo" (man, Cons B).
Narrative exposure prompted substantial discussion about possible solutions to childhood obesity. However, across political ideologies, most discussions ultimately placed most of the responsibility in the hands of parents, often commenting on the need for obesity education. These statements acknowledge that parents need more information but focus on internal parental decisions as paramount for reducing obesity in children.

Most important solution: postnarrative exposure
After discussing reactions to the stories, we asked participants to identify the single most important thing that could be done to reduce obesity rates. More than half of the participants that read the adult story responded with external solutions (eg, insurance company incentives, workplace programs, tax policies). In contrast, only 1 participant in each of the 2 groups that read the childhood story mentioned external solutions (eg, universal health care, restaurant portion size restrictions).

Discussion
The analysis revealed 4 main themes. First, although both liberal and conservative participants viewed internal factors as the primary causes of obesity, most also acknowledged that external factors play an important role. Second, regardless of political ideology, participants offered internal solutions focused on reducing knowledge deficiencies as primary strategies to reduce rates of obesity. Third, consistent with previous work (10), conservatives voiced resistance to many external solutions, particularly legislative options. Fourth, both liberals and conservatives responded more favorably to a story emphasizing barriers to reducing adult obesity than to one emphasizing barriers to reducing childhood obesity, despite comparable efforts by the characters to reduce their (or their child's) weight.
Consistent with previous work, our findings suggest that many adults conceptualize obesity as a condition that is primarily the responsibility of individuals or parents (9). Internal responsibility was the starting point for discussions about external causes, and many participants rejected the idea of legislative solutions to address obesity. Nevertheless, obesity-reducing efforts will be unsuccessful without policy changes. These factors underscore the importance of developing messages that acknowledge individual decisions while emphasizing external causes and solutions. Future studies might assess, develop, and test strategies to 1) acknowledge individual decisions but 2) refute the idea that these factors alone cause obesity (11,22).
Both liberals and conservatives identified several external causes of obesity. Nevertheless, participants in all groups offered few external solutions to address these issues. These results suggest that advocates and researchers would benefit by developing and testing strategies to raise public awareness of other policy and legislative options at multiple levels of intervention (eg, school, workplace, community, national).
Findings also suggest that some types of narratives may promote support for policy solutions. Both liberal and conservative groups expressed empathy for the adult story's main character and focused their attention on external factors that cause obesity. Narratives that generate empathy and call attention to external causes of obesity thus appear to have the potential to generate support for obesity-related policy change (8). At the same time, little is known about specific elements of narratives that maximize effectiveness in behavior or policy change (13).
The childhood obesity narrative, although explicitly designed to emphasize external causes, generated substantial criticism toward the child's parents. A focus on childhood obesity may inadvertently prime or activate existing beliefs about parental attribution of responsibility for childhood obesity (23,24). Future work should assess whether different narratives are more effective in promoting broader societal concern and attribution of responsibility for childhood obesity.

Limitations
This study reports on 4 discussions among a small sample of predominately white adults living in a midsized Midwestern community. Results are not generalizable to the broader US population but are meant to serve as a starting point for further empirical testing of effective message strategies for upstream policy change. Although both messages were designed to emphasize external barriers to achieving a healthy weight, there are other ways to tell stories that emphasize these issues. The 2 stories differed substantially in plot (losing weight vs avoiding gaining weight), character (male [John] vs female [Jimmy's mom]), and setting (urban vs rural). Differences in these factors may also explain differences in audience responses to them. In addition, the demographic composition of the sample (ie, predominately white and more than half without children) may have shaped responses to the adult and child obesity narratives. Centers for Disease Control and Prevention • www.cdc.gov/pcd/issues/2011/mar/10_0067.htm The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Conclusion
This study's results provide a deeper context of understanding public perceptions about obesity. Results suggest that some narratives emphasizing barriers to diet and exercise may help to generate support for obesity-related policy change. Next steps include 1) formally testing the effectiveness of narrative message strategies for generating support for specific policies and 2) identifying specific story elements that enhance or reduce effectiveness.